The Voice of Podiatrists

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August 13, 2007 #3,012 Editor-Barry Block, DPM, JD

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CA Podiatrist is Runner, Race Course Designer, and Treats Competitors

When runners cross the finish line of The Hills Are Alive 5K/10K in Rolling Hills Estates Saturday, a familiar face will be there to greet any finishers who are in need of medical attention. Blisters? No problem. Sprained ankle? He'll have tape and ice at the ready. And thank-yous are not required. Podiatrist Dr. John Pagliano has been treating race participants trail-side in addition to running in the 10K portion of the event every year since the race's inception in 1982.

Dr. John Pagliano

The 68-year-old Pagliano admitted he has walked a few of the races because of injury, but he has never failed to complete the 10-kilometer race. Even while going through treatment for non-Hodgkin's lymphoma in 2004, Pagliano still competed in and completed the race.

Aside from running in the race, Pagliano has also played a key role in developing the course into what it is today. As a member of the city's Parks and Activities Commission, Pagliano used his extensive knowledge of the local horse trails to firm up the race's course. "It's really a unique race," Pagliano said. "It's probably one of the only runs that I can think of that is still run on dirt and grass, which is the real spirit of cross country."

Source: David Saunders, DailyBreeze.com [8/10/07]

Barry Podiatrist Demonstrates Value of Education & Training

When Ana Cruz came into the Barry University Foot and Ankle Institute, a new teaching clinic in Bay Harbor Islands, her injury seemed to be a classic ankle sprain.

Dr. Jacqueline Brill

But when Dr. Jacqueline Brill took a closer look, she saw there was more to the problem. Cruz recently fell while getting into her car during a rainstorm, and she not only sprained her ankle, but also caused a break in the fibula bone near her knee. She would eventually be admitted to Mount Sinai Hospital for surgery, but first came the exam at Barry's new clinic.

As Brill treated her, two students and a resident watched, and learned a lesson the doctor said was crucial. "If they don't have the training and educational background, they won't know to look for more," Brill said. "If that woman started walking on that foot, she would have been in big trouble."

Source: Gina Pace, The Miami Herald [8/9/07]

Richardson Announces Universal Health Insurance Proposal

Presidential candidate New Mexico Gov. Bill Richardson (D) on Tuesday announced a proposal that would extend health insurance to the 45 million U.S. residents who lack coverage and would not require a tax increase, the Washington Post reports. Under the proposal, all residents would have to obtain health insurance. The proposal would:

•Allow residents ages 55 to 64 to pay to participate in Medicare, expand Medicaid and SCHIP to include more low-income children and families and allow young adults to continue to receive health insurance through the policies of their parents until age 25;
•Provide tax credits on a sliding income scale to help residents purchase health insurance
•Allow residents and small businesses to purchase the same health insurance offered to members of Congress and the president;
•Mandate that health insurers no longer can deny coverage to residents with pre-existing medical conditions;
•Provide veterans with a "Heroes Health Card" that would expand their access to healthcare;
•Require employers to pay a share of health insurance costs for employees or help uninsured residents purchase coverage;
•Limit interest rates applied to healthcare costs charged to credit cards;
•Allow the federal government to negotiate prices directly with pharmaceutical companies under the Medicare prescription drug benefit;
•Establish incentives for preventive care programs; and
•Improve healthcare efficiency though increased use of technology and other measures

Source: Multiple Sources via American Health Line [8/8/07]

Query: Red Blotches on Plantar Surface of Feet

I would appreciate any help with diagnosis or recommended further testing. The patient is a 12 year old Afro-American female referred by her internist, who she had seen. She began getting painful red "splotches" on her left foot 3 months ago, followed by her right foot 1 month later. There is no history of illness, loss of appetite, weight loss or gain, lethargy nor joint pain.

Red Blotches on Plantar Surface of Feet

There have been no new shoes, socks, detergents, etc. Her temperature is normal and there are no lesions anywhere else on the body. Blood work is normal, other than a slightly elevated PT of 15.7 (lab norm <15) and MCV of 79.2 (lab norm >81). Her WBC is 10.4 (lab normal < 10.6). The "splotches" are slightly raised, warm, solid, and extremely painful upon palpation. They have not changed color or size in the past two months. They are not skin lesions.

Burton J. Katzen, DPM, Temple Hills, MD

RE: Loupes (James M. Petko, DPM)
From: Multiple Respondents

Designs For Vision telescopes are excellent. Although I only need them for a few particular procedures, I do almost everything better with them. So I use them constantly. (They come in handy when my staff needs me to read the microscopic ID numbers on insurance cards!) I have looked into other brands at meetings. Nothing comes close. They are comfortable, sturdy, and well-balanced. A representative will measure and fit you to get your exact intra-pupillary distance. He will also have you hold your hands out to get the optimal focal point exactly where you work. They are well worth the relatively high price.

Richard Gosnay, DPM, beautifulbaldhead@hotmail.com

I advise trying a jewelry supply house. In Tampa I use B. Rush Apple. They sell an excellent headset with a swing away additional magnification lens. It has served me well for years. This is assuming you do not wear glasses. If you do, they also have a clip on binocular magnifier but field of vision is smaller.

Barry C. Blass, DPM, Tampa, FL, footdoc@verizon.net

I think an investment in loupes, which can run into hundreds of dollars is an expensive way to deal with foreign bodies in the office. I use magnifying glasses that clip to my eyeglasses. I got them at a conference from keystone medical instruments for about fifty dollars or so. I keep a pair in every treatment room and in my house call bag. Their phone number is (866) 861-8950. They also carry loupes but save those for true surgical procedures

David Gutierrez, DPM, DOCG2100@aol.com

Grastontechnique.com should help you out explaining the technique. It is supposed to be a soft tissue immobilization technique performed with instrumentation that does not come cheap. I believe the original inventor of the instruments now competes with the brand that "owns" his name.

Jeffrey Kass, DPM, Forest Hills, NY, Jeffckass@aol.com

I have referred a some of my patients who did not respond to traditional treatments for tendon pathologies such as chronic Achilles tendonitis/tendonosis, chronic plantar fasciitis, and other entheseopathies. There is a chiropractor in my office who is well-trained in this technique and with the Graston instruments. I have found it very effective in these select cases and usually requires 4- 8 treatments to see benefits. The patients that I have referred have failed injection therapy (where appropriate), orthotic therapy, physical therapy by a physical therapist, home stretching and exercising, and other standard treatments.

Vincent C Marino DPM, San Francisco, CA, drmarino@marinofootandankle.com

From what I know of the Graston Technique, a type of Instrument Assisted Soft Tissue Mobilization (IM), there is not much special about it. Here is an article to get a better understanding of what it is.
http://etd.lsu.edu/docs/available/etd-06232004-162858/unrestricted/Burnside_thesis.pdf

Different shapes of stainless steel are used to "run over" the patient's body to detect "fibrosis" or other pathology and adhesions. The instrument is then used to traumatize the tissues, and from what I suspect, convert the chronic inflammatory process back into an acute process. Detection of the adhesions it is similar to what we used to refer to as the "pocket MRI." This was simply the application ultrasound gel to the patient to help your fingers glide over the tissues to get a better feel of the underlying structures.

As far as the treatment is concerned, I say it is nothing special since I see it as nothing more that another way of traumatizing tissues to patient tolerance in a clinical setting. I suppose one could use just about anything to traumatize a tissue into the inflammatory phase, which does appear to work with some conditions. If it were me, I would rather undergo shock wave treatment and get it over with rather than enduring hours of painful physical therapy. If there are more compelling studies out there I have not seen them.

Jon Purdy, DPM, New Iberia, LA, jpurdy@mindspring.com

RE: Test to Confirm That Osteo Has Resolved (Edward Orman, DPM)
From: Marc Katz, DPM, Paul Kesselman, DPM

Regarding resolution of osteo and the use of Sed rate and CRP. In my opinion these are not reliable indicators especially in a distal phalanx. Many of the patients that I see with osteo have no WBC elevation, no left shift and normal Sed and CRP. I would be careful with those values. Again clinical signs and symptoms are the biggest factor.

Marc Katz, DPM, Tampa, FL, dr_mkatz@yahoo.com

Theoretically, the gold standard for diagnosing the presence of osteomyelitis remains a bone culture and biopsy. Both should be done on specimens which can be taken under radiographic guidance through an uncompromised site. If either is positive you would be well justified in resecting this small fragment of bone and treating for o/m. Doing a biopsy on such a small site would admittedly be quite difficult on a distal phalanx of a lessor toe.

Sed rates on their own are not reliable, but over the course of time one should theoretically see a gradual decrease. The infectious disease specialists at my hospitals and I look at the C Reactive protein as a more reliable hematological indicator as opposed to the ESR.

Non invasive HMPAO (white cell tagged scans) are far more reliable than almost any other non invasive study. MRI just won't give you the detail you would need on a small distal phalanx.Using techique, its going to be very difficult to read these reliably on such a small area unless the films are magnified.

Ultimately, I believe osteomyelitis is a surgical disease. Even 6 weeks of parenteral antibiotic therapy combined with surgical excision is no guarantee of a cure. In general, I treat w/antibiotics for two weeks when the remaining stump of bone has no growth and the biopsy is negative for osteomyelitis. Treatment is 6 weeks when either culture or biopsy is positive. In either case, the patient is also monitored very closely for any signs of recurrence (systemically not just in the foot).

I've unfortunately seen one 40 y/o patient die of bacterial endocarditis as a result of refusal to undergo proper treatment for osteomyelitis. I believe you need to warn your patient of the dire consequences of inappropriate treatement. The patient should also be followed by an infectious disease specialist.

Paul Kesselman, DPM, Woodside, NY, pkesselman@pol.net

Editor’s Note: This topic is now closed.

Staff Privileges at Certified Surgical Facility Available- NY & LI

Certified operating rooms which qualify under the new NY Patient Protection Law (which will require accreditation for in-office procedures) are available in Manhattan East 60th Street and Plainview, Long Island. Staff privileges still available. Call 516 433-4447 for information or e-mail podo2345@aol.com

ASSOCIATE WANTED - PHOENIX, AZ AREA

A well established, ethical solo podiatry practice wishes to expand its current surgical services in the near future by hiring a full-time associate with PSR 24-36 training which includes very strong surgical rear-foot and ankle reconstruction, diabetic limb salvage and ER trauma. Successful association may lead to partnership. ABPS Board qualified/certification is required. Applicants must be personable and caring to patients. Practice in an office base within a new state-of-the-art orthopedic surgical hospital environment and plenty of future expansion capabilities for a bright, eager, reliable associate. Email complete CV with current references & photo to footdoc352@cox.net

ASSOCIATE POSITION - NORTH TEXAS

Looking for motivated, hardworking, personable individual with minimum PSR/24 training. The practice has been well established in the community for over 20 years. Our practice offers a large self-owned office, State-of-the-Art Surgery Center, and competitive salary with profit sharing. Send CV with references to info@ntfootcare.com, or fax to 903 868-2975.

PRACTICE FOR SALE--LOS ANGELES, CA AND VENTURA, CA

Selling fully equipped practice in Los Angeles. Located in medical office building with ample free parking. Satellite office in Ventura, CA can be sold separately or together. Potential for further future growth. Sale price comparable to the cost of starting a new practice. Inquire at tkhk@sbcglobal.net

ASSOCIATE POSITION -CONNECTICUT-NORTH HAVEN

Seeking a part-time associate for a busy, well-established, respected, growing practice. Desiring an ethical, motivated, personable, well-trained PSR12/24/ or 36 podiatrist. Our practice is well-rounded and diverse with a good mix of sports medicine, diabetic care, surgery, podopediatrics, and general podiatry. Email information and CV to Pedy7@aol.com with subject heading “Podiatry Associate.”

ASSOCIATE POSITION SANTA FE, NEW MEXICO

Immediate opening for PSR 24/36 individual in three office practice. We are looking for an ethical, hard working, well trained Podiatrist. Partnership available. Please Fax CV to sfpodiatry@aol.com

PODIATRIC FELLOWSHIP POSITION AVAILABLE – CALIFORNIA

This one year fellowship will emphasize reconstructive foot/ankle surgery and research. Located in beautiful Sonoma Valley California. Must have a current California license and have completed a PSR-24,PM&S 24,or PM&S 36 residency program. Please send all letters of interest and a recent CV to Thomas Chang, DPM, Director, at podiatricri@yahoo.com or call (949) 412-8445.

PODIATRISTS NEEDED - CHICAGO --NORTHWEST INDIANA

Home Physicians, a medical group specializing in house calls is looking to hire podiatrists. We are located in Chicago and Northwest Indiana. Full and part time positions are available. Competitive Compensation including malpractice. Contact Scott Schneider. Phone-773-292-4800. Fax 773-342-4201 -E-Mail sschneider@homephysicians.com -- www.homephysicians.com

ASSOCIATE POSITION – GREATER BOSTON AREA

Full-time comprehensive practice with hospital teaching affiliation west of the greater Boston area looking for motivated, ethical, surgically trained podiatrist. Competitive salary and benefits. Call 508-872-9288

ASSOCIATE POSITION - SOUTHERN NEW JERSEY

Busy multi-dimensional practice. 20 minutes from Philadelphia. Board qualified/certified ABPS. Ethical, motivated, personable. Starting 65K plus health, malpractice, CME, bonus incentive. E-mail resume TotalFootCare@aol.com

ASSOCIATE POSITION - NORTHWEST PENNSYLVANIA

Multi-specialty group is looking to add another Podiatric Surgeon or General Podiatrist to our well-established group. Office locations in northwestern Pennsylvania. Unlimited opportunities exist for the right Associate, wound care experience is a plus. Please forward your CV to adminsec@ips-mso.com

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